Country to be visited
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1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________ 4. _____________________________________________________________________________________________________ 5. _____________________________________________________________________________________________________ 6. _____________________________________________________________________________________________________ Please circle the descriptions that best describe your trip 1.
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Other……………………………….
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_____________________________________________________________________________________________________ Personal medical history Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder. _____________________________________________________________________________________________________ List any current or repeat medications. _____________________________________________________________________________________________________ Do you have any allergies, for example to eggs, antibiotics, nuts? Patient Name: Date of Birth:

Have you ever had a serious reaction to a vaccine given to you before? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Does having an injection make you feel faint? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you or any close family members have epilepsy? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you have any history of mental illness, including depression or anxiety? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Have you recently undergone radiotherapy, chemotherapy or steroid treatment? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Women only: Are you pregnant or planning pregnancy or breast feeding? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Have you taken out travel insurance? If you have a medical condition, have you informed the insurance company about this? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Please give any further information that may be relevant, including any future travel plans. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Vaccination history

Have you ever had any of the following vaccinations/malaria tablets, and if so, when?
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_____________________________________________________________________________________________________ Other _____________________________________________________________________________________________________ Malaria tablets _____________________________________________________________________________________________________ For discussion when risk assessment is performed within your appointment: I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given. Signed:
For official use

Animal research highlights a therapeutic potential of cannabinoids for the treatment of depression Regina A. Mangieri Department of Pharmacology, The University of Texas at Austin, Austin, TX 78712, USA Abstract Long known for their mood altering effects, cannabinoids are currently under investigation for their therapeutic potential in the treatment of depression. Findings from multi